HomeMy WebLinkAbout1749A (10) WORKERS'COMPENSATION DECIARATION � �
� I"hereby af(irm thot I have a ceriificote of�o�,e��,e se�f - qpp��CATION FOR BUILDING PERMIT
insure,�or o certiFitare aF Workers'Compensa�ien Insurante,
or a c�rtified copy ihereof(Sec.3800,Lab.C.) � -
COUNTY OP LOS ANGELES BUILDING AND SAFETY
P:y!cy No. Compony �
LJ �er;ified copy is hereby furnished. FOR APPLICANT TO FIIL IN BUIIDING
OADDRES$ Z ,
CerGfied copy is filed w�ih ihe coomy bu�ld�ng inspec- gU4DiNG i
tion deportmenl. ADDRESS
Date Applicant CIN ZiP LOCAIITV
CERTIFI�ATE OF EXEMPTiON FROM WORKERS' rio.ov eio�s. n�neEST
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CRO55 ST. �
Qhis setiion need not be compieted if the permit is for one - TRAR 3 BLOCK � tOT n10. �ESSOR
hundred doilars(E100)or less.) AMG BOOK PAGE PARCEL
TEL. � _ �5E ZONE �P
I tertify Ihat in the periormance of the work for which ihis �NER p � � �
permif Is issued,I ehall not employ ony person in ony monner qD�RE55�� � CONDITIONS U �
so os to become s�bject to the Workers'Compansation laws. � �
at ziv V
Dote Applimnl � ARCHITEROR TEL. �
NOTICE TO APPLICRNT: If, after making this Cartifitate of , � oiStRiCT GROVa �NST. ZONE SEO er p
Exemption, yo� sho�ld become s�bject fo the Workers' � ENGiNEER No.
� Compensotion provislons of ihe Lobor Coda,you musl forth- qpDrtE55 ��� F//F�F�.�) � . � �''3 � 3 W
winc �omply with svch provlaions or this permit shcll be - E. STATISTICAL QASS�FICATION APT. CONDp.n n"
deemed revoked. CONIRACTOR f � � � �f z
LICENSED CONTRACTORS DECIARATION ���. CtA55 NO. DWELL.UNITS
I he�eby affi�m that I am licensed under provisioM of Choprer 9 ADDRESb1�� . NO. �yyER Mnnv
(commencing with Secrion 7000)o(Division 3 of the Bvsinau and
Pro�essions Code,ond my litense is in full force and effect CRy - OW Ne�S /LJL' gK � VAUDATION
5�.FT. NO.OF NO.OF CHECK
Llcense Number Li[.CIOSs SIZE �� SiORIES FAMILIES ONE
� a VALUATION p.7
- DESCRIPTION OF WORK N� /�3�a_
Coniroctor Dale AOD s �
�I am exempt�nder Sec. A��R ❑
� =� 7 l+.�a
8.8P.C.far this reoson � pEpp�R � � . .
USE OF DEMOI ❑ � • • �
Date: EXISTING BLDG. t .
Signature - iE. FINALn��q � 1 ° � � �p�
OWNER-BUILDER DECLARATION PRINT .� � DATE V�/J�
I hereby afFirm thot I am ezempt from the Contrac�or's Licensa � p�
Law for the following reozon(Section 7031.5.8usiness and A��R`-u FINAL • ° � � '' )U T --
P�essionsCode): p E tv Sy
BUIlOiNG
I, as owner of tha pioperty, or my amp�oyees with aDDRE55 �;�� �_n 7
woges es iheir sola compensatlon,will do tha work and , ���r
Ihe shocfure b nol inlanded or offered for sale(Section ����TY - -
70l4,Business and Prafesslons Cade). MOVING - -- --TEI. ' '�� � •
� I,os owner oi the property,om ezclusively cantmcting �ONTRACTOR NO. v-}� {i ,
wirh Iicensed mntracrors to constroct rhe prajeu(Sec- qookE55
tion 7044,0us�ness end Proiessions Code). ,��,j `���:����
- CONSTRUCTION LENDING AGENCY REQwRED IOini SErenCK r+� xi
$E T B A C K YARD HWY p{t p p.L I N E W I D T H `
I hereby affirm Ihot there is a tonstrutlion lending agency for fRONi �r( �C�^�'
tha pe�formance of the work(or which this permit is issued P1 . 1."!J��
(Sec.3097,Civ.C.). sioE '
v.i. - �'5 "�f,f^r
Lender's Name O�J, tpMA Ref.M `� ' �t�;
��.
Lender's Address P.[.Fee E Pe�m�t Fee /
1 certify ihot 1 have reod this applitation and state that the �ssuance Fee � iDMA P/C M � �
abvve informotion is correcl.I agree to comply with oll Counry Invee�igo��on fee p- p •
ordinonces and State laws relating to building constr�ttion, Towl Fee O LDMA Pe.m.M
and hereby aulharize rapresentolives o(thfs County fo enrer
upon Ihe abo e•mentioned propert fo i spection purposes.
�` SEE REVERSE FOR F%PLANATORY IANGUAGE
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